USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 40
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Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (thc only definite synonym is "Epideinic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of.
(namnc origin; "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions,"""Debility" ("Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train -accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized 1 discase, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 2-'18. 100,000.
1
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
10wall. .......
(City or town)
1 PLACE OF DEATH
County.
State
Township
or Village
or
City
No.
St., .. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
(a) Residence.
No
Chaleurford Our Way.
.Ward.
(Usual place of abode)
Leogtb of resideoce in city or towo wbere death occurred
years
mooths
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Female Vita
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married
5a If married, widowed, or divorced HUSBAND of (01) WIFE of
Loris alfred brenner
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
Months
Days
If LESS thao 1 day, ........ hrs. or ........ mio.
8 OCCUPATION OF DECEASED-
(a) Trade, profession, or particular kind of work ..
House Life
(b) Geoeral nature of industry, bosioess, or establishment io which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town).
Canada
Lane
(State or country)
10 NAME OF FATHER You Award
1 BIRTHPLACE OF FATHER (city of town) accada (State or country)
12 MAIDEN NAME OF MOTHER Marien Jooler
13 BIRTHPLACE OF MOTHER (eity or town). (State or country) Canada
14 Ayetand Informant
(Address)
15 Filed act -1, 1918/ Edward JRebbe
REGISTRAR
16 DATE OF DEATH (month, day, and year) Jekt. 29 1918
17 I HEREBY CERTIFY, That I attended deceased from Je/11-20, 1918, to Next 24, 19/2.
that I last saw h. ......... alive on
, 19.15.
and that death occurred, on the date stated above, at
10 A.
.m.
The CAUSE OF DEATH* was as follows :
Fabular Pre Alla
(duration)
.yrs ....
mos ....... ds.
CONTRIBUTORY (SECONDARY)
... (duration)
yrs.
mos.
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?
Date of.
Was there an autopsy ?
What test confirmed diagnosis ?
(Sigoed)
MI.D.
/2, 19 / } (Address) 732 ellerneue 12
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
20 UNDERTAKER
a'archambaud
ADDRESS
731 Werk
house.
MARGIN RESERVED FOR BINDING
PARENTS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
Maria Framer
(If non-resident give eity or town and State)
25
Registered No. 67
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Ilealth Association]
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architeet, Locomotive engineer, Civil engineer, Stationary fireman, ete. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when necded. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ete. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- eifieally the oceupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, ete. If the oeeupation has been changed or given up on account of the DISEASE CAUSING DEATH, state oeeupation at beginning of illness. If retired from business, that fact may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death .- Namc, first, the DISEASE CAUSING DEATH (the primary affeetion with respect to time and eausation), using always the same aeeepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); "Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, ete., Carcinoma, Sarcoma, ete., of_
(name origin; "Caneer" is less definite; avoid use of ."Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (secondary or inter- current) affeetion need not be stated unless important. Example: Measles (disease eausing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatie), "Atrophy," "' "Col- lapse," "Coma," "Convulsions," "Debility" (“Con- genital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shoek," "Uremia," "Weakness," " ete., when a definite disease ean be aseertained as the eause. Always qualify all diseases resulting from ehild- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. State eause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fraeture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of eause of death approved by Committee on Nomenelature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violenee, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ete.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be duc to Alcoholism, ete.
4. Deaths under eireumstanccs unknown, as A person found dead, ete.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY PHYSICIAN.
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town)
Registered No. 68
Township
1
City.
Z
con Village
Road.
.. or
St., ............ .. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number) therforte.
2 FULL NAME
(If in the Army or Navy of the United States, gi
, Biye rank, organization, etc.) .
St ..
.. Ward.
(If non-resident give city or town and State)
(Usual place of abodc)
Length of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
~
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
-
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
U.
Months
Days
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work ..
(b) General nature of industry, business, or establishment in which employed (or employer) . (c) Name of employer
9 BIRTHPLACE (city or town).
(Statc or country)
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (city or town)
1 1
(State or country)
12 MAIDEN NAME OF MOTHER Marca Moram/2, 1918 (Address)
13 BIRTHPLACE OF MOTHER (city of town) /// (State or country)
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
DATE OF BURIAL
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
XT Patrie ler Laurel, Cet2. 19/5
20 UNDERTAKER
ADDRESS
15
File Dati 2 1915 Edwood Rolling
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year), 19/
17 I HEREBY CERTIFY, That I attended deceased from Sept 20, 1918, to Seht 30, 1918
that I last saw h Was alive on
Sept 20, 1918
1. ª La
m.
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows :
Bunchof
monia
5 ds.
CONTRIBUTORY
(SECONDARY)
(duration) Influenza
(duration)
... yrs ...
mos 10
.ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?
no
Date of.
Was there an autopsy ?.
no
.
What test confirmed diagnosis ?.
10 (Signed)
M.D.
PARENTS
of certificate.
14
Informant
Hared DuckQuanly
.......
(Address)
MARGIN RESERVED FOR BINDING
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
126
......
1 PLACE OF DEATH
County ..
Hidellexix,
State
(a) Residence.
No
......
............. yrs ..........
.... mos .......
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATII [Approved by U. S. Census and American Public Health Association]
1
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to cach and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, ete. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborcr," "Foreman," 1." "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ete. Women at home, who are engaged in the duties of the houschold only (not paid Housekcepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spc- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Houscmaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- eated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write Nonc.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to timc and causation), using always the same accepted term for the same discase. Examples: Cerebrospinal fever (thc only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria .(avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pncumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of_
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (discase causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as " Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" ("Con-
"Exhaustion," genital," "Senile," etc.), "Dropsy,"
"Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease ean be ascertaincd as the cause. Always qualify all discases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- ' PERAL peritonitis," etc. State eause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 2-'18. 100,000.
1918- 46-
187%
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should stato CAUSE OF DEATH in plain terms,
The Commmuralth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County.
Middlesex
State Masa.
Registered No. 6.
Township
City No.
or Village.
Chelmsford
... or
South
St.
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
George Biron Samphere
(a) Residence. No (Usual place of abodc)
Length of residence in city or town where death occurred
years
mooths
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male.
4 COLOR OR RACE
arhite.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married.
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Mary E. Samphere.
6 DATE OF BIRTH (month, day, and year) Seft, 27.1872.
7 AGE
46
Ycars
Months
Days
4
If LESS thao 1 day ......... hrs. or ........ mio. Broncho. pneumonia
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
Paper Hanger
particolar kind of work ..
(b) General nature of industry,
business, or establishment in
Paper Hanger.
which employed (or employer).
(c) Name of employer
9 BIRTHPLACE (city or town).
Chelmsford.
(State or country) Mare.
10 NAME OF FATHER
Albion & Samphere
11 BIRTHPLACE OF FATHER (city or town) Lebanon (State or country) N. H.
PARENTS
of certificate.
14 Mra. Mary E. Samthere Informant 1 (Address) Chelmalfordy Hace.
15 Filed. Oct. 2 1918 Edurand te Sotto220
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Do 1, 1918.
17
I HEREBY CERTIFY, That I attended deceased from
Sept. 28
, 1918, to.
., 1918
oct. 1
that I last saw h /m alive on
oct.1
1918.
and that death occurred, on the date stated above, at
9.30 A. m.
.m.
The CAUSE OF DEATH* was as follows :
(duration)
... yrs.
mos ...
ds.
CONTRIBUTORY.
Influenza
--
(SECONDARY)
.(duration)
X
.. yrs ..
mos.
10
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death? Www. Date of
Was there an autopsy ?.
What test confirmed diagnosis ?..
Physe
y secal.
(Signed)
Almasa Howard
M.D.
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL., SUICIDAL, or HOMICIDAL. (See reverse side for additional spacc.)
DATE OF BURIAL, 19 PLACE OF BURIAL, CREMATION, OR REMOVAL_ Forefathers Com. Chelmsford, Oct, 1 1918.
20 UNDERTAKER.
ro Matealey.
ADDRESS 79 Branch 86
ee 1.)
be
South
St.,
Ward.
(If non-resident give city or town and State)
MARGIN RESERVED FOR BINDING
127
Chelmsford. (City or down)
12 MAIDEN NAME OF MOTHER
Mary J. Atwood.
, 19
(Address)
Chelmsford, Mais.
13 BIRTHPLACE OF MOTHER (city or town) Bradford (State or country) N. H.
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Preeise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Forcman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestie service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on aceount of the DISEASE CAUSING DEATH, statc occupation at beginning of illness. If retired from business, that fact may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fcver (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of_
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Mcasles (discase causing death), 29 &s .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapsc," "Coma," "Convulsions," "Debility" ("Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite discase can be aseertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of dcath approved by Committec on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or onc supposed to be due to Alcoholism, etc.
4. Deaths under cireumstanees unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS
BY
PHYSICIAN.
R 15. 1-'18. 100,000.
.
128
Lowell
CERTIFICATE OF DEATH OF NON-RESIDENT
(City or town)
16/3
County ........****..
middlesex
State
mars
Registered No ..
(Place of death)
Registered No ..
70
(Place pf residence)
St ...
.......
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
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